Facility Accreditation for Canadian Certified Pedorthists. Approved March 5, 2007

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1 Approved March 5, 2007

2 1.0 General Outline 2.0 Facility Titles 2.1 Definition of a Facility 2.2 Distinct areas of Accreditation Index 2.3 Multiple Accreditations in a Facility 3.0 Accreditation Process 3.1 Application Overview 3.2 Application Completeness 3.3 Application Fee 3.4 Annual Ongoing Accreditation Fee 4.0 Standard Requirements for Facility Accreditation 5.0 Documentation Review 6.0 Facility Description and Supporting Documentation 7.0 Facility Layout 8.0 Tools and Equipment 9.0 Facility Inspection 10.0 Accreditation Decision 11.0 Appeal Process 11.1 When Appeal can be Taken 11.2 Appeal Deadlines 11.3 Addressing the Appeal 11.4 Appeal Documentation 11.5 Appeal Decision 12.0 Maintenance of Good Standing 12.1 Failure to Pay Annual Dues 12.2 Minimum Standards 13.0 Temporary Cessation of Facility Accreditation 13.1 Guidelines for Notification 13.2 Duration of Temporary Status 14.0 Requests for Information 15.0 Release from Liability 16.0 Effect of Signing 17.0 Communication of Accreditation Appendix 1: Facility Accreditation Application Appendix 2: Accreditation Process Flowchart Updated April 17,

3 CPC Accreditation of Facilities Application Guideline 1.0 General Outline In response to new requirements within certain provinces, The College of Pedorthics of Canada (the CPC ) offers voluntary facility accreditation for the designations C Ped (MC) and C Ped (C). The purpose of the accreditation is to create a set of standards that: A) give assurance that such facilities are able to provide the highest quality of care for patients and referring professionals, B) to ascertain that the physical environment and working conditions meet acceptable standards of safety for staff and the public, C) to create a national standards level for Pedorthists to follow when designing, purchasing or modifying a Pedorthic facility. 2.0 Facility Titles 2.1 Definition of a Facility : The term Facility means: (a) (b) (c) (d) (e) (f) the physical building and its layout; the staff working in the physical building; patient files located in or relating to the physical building; equipment located in the physical building; materials used to manufacture orthotics or to modify footwear; and parking area used by patients and staff visiting the physical building. 2.2 Distinct Areas of Facility Accreditation: 1. Custom and Non Custom Foot Orthotic Fabrication / Supply 2. Custom Footwear Fabrication / Supply 3. Non-Custom Footwear Supply / Modification Updated April 17,

4 2.3 Multiple Accreditations in a Facility Pedorthists may elect to certify in any or all of these areas as long as they meet the individual criteria outlined for each area in this document. Facility accreditation for one area does not assure accreditation in either of the other areas. 3.0 Accreditation Process 3.1 Application Overview Applicants wishing to pursue Facility accreditation must fill out the required documentation completely and return it to the CPC. 3.2 Application Completeness All information required on the application must be furnished. Incomplete application packages will be returned without processing. 3.3 Application Fee The CPC will review and set the application fee (the Application Fee ) for Facility accreditation yearly, which Application Fee will be stated on the Facility accreditation application form. The Application Fee must accompany the application when filed. Applications not accompanied by the Application Fee will be returned. All applicants (including secondary Facility locations) are required to pay the Application Fee to cover the costs of the initial accreditation process at the time of application. The Application Fee is NOT refundable if the Facility does not receive accreditation. 3.4 Annual Ongoing Accreditation Fee If accredited, the Facility will be required to pay an annual ongoing accreditation fee (the Annual Fee ) for ongoing record maintenance and incurred inspection costs. The CPC will review and set the Annual Fee for Facility accreditation yearly. The first Annual Fee will be due at the time of application for year one and then in January of every year thereafter. In the event accreditation is not granted at the initial accreditation review, the first year s Annual Fee will be returned to the Facility. Secondary Facility locations will pay a reduced Annual Fee. Updated April 17,

5 Failure to pay the Annual Fee by the annual due date will result in accreditation being revoked from the Facility. 4.0 Standard Requirements for Facility Accreditation The CPC awards its certificate to Facilities that give evidence that: A) the Facility is managed by a C Ped (C) or a C Ped MC, whose membership with CPC and the Pedorthic Association of Canada is in good standing, who is accountable for the quality of all conducted services at the facility; B) all work is performed or monitored by a C Ped (C), a C Ped MC, or a C Ped Tech (C); C) the Facility meets the CPC minimum requirements as to Facility lay-out, appearance, equipment and safety standards, as attested to in writing by the Facility manager; and D) the Facility maintains complete and accurate patient files as outlined in the CPC s Code of Ethics, as well as its Standards of Practice; and which fulfill all the other requirements set out in this document. 5.0 Documentation Review The CPC shall review all applications in the order in which they are received. A Facility Accreditation Committee (the FAC ) will receive and evaluate the documentation and data submitted by the Applicant. It will determine whether it meets the Requirements set out in this document. 6.0 Facility Description and Supporting Documentation Applications must include the following: A) A complete copy of the current floor plan of the Facility. This copy should indicate the purpose of the rooms in the Facility and where any manufacturing equipment is placed. B) Digital file containing good, clear quality images showing at least two views of the following: The reception area The laboratory area (If applying for Custom and Non-Custom Foot Orthotic Fabrication/Supply or Custom Footwear Fabrication/Supply) Updated April 17,

6 *** Please note that photos of the lab area must clearly include all required machinery. One assessment room Retail space (If applying for Non-Custom Footwear Supply/Modification) Front of the building C) A copy of the current license to operate a business as required by the Facility s jurisdiction, including any licenses or approvals required to operate a business of the type conducted by the Facility. 7.0 Facility Layout The Facility layout and physical structure must meet each of these criteria in order to obtain accreditation: A) The building itself on the exterior and interior must have a professional appearance. B) The front office and reception area must be large and comfortable enough for the daily patient load, including ease of movement for disabled patients. C) A secure filing area must be on site for patient records, which are to be stored in accordance with any and all applicable laws and regulations. D) Separate assessment / fitting rooms with privacy from the general public and other non-related commercial areas. E) The laboratory must be separate from the reception, waiting and assessment rooms. F) The building must meet all codes for people with disabilities. 8.0 Tools and Equipment To warrant accreditation, the facility and applicant must have tools and equipment in good working order along with the proper safety protection required for its use. (See attached questionnaire section). 9.0 Facility Inspection The CPC may send an official appraiser from across Canada to inspect the Facility. This process will be a random audit. The appraiser will hold either a C Ped MC or a C Updated April 17,

7 Ped (C) certification with a minimum of 5 years experience since becoming certified by the CPC. The inspection will: A) determine that there is sufficient safety equipment for the staff and public; B) determine Patient information is stored in an orderly and secure fashion in accordance with any and all applicable laws and regulations; C) determine that staff members know what WHMIS is (Workplace Hazardous Materials Information Systems); D) determine what is the overall physical condition of the Facility (e.g. condition of floors, doors and walls); E) determine that there is sufficient stock of items to be used in the area of accreditation application (e.g. shoe stock or plastics / foam for orthotic manufacturing or modification; and F) review an accurate work schedule of certified staff along with the hours the facility is to be operating Accreditation Decision Within days from the start of the accreditation review process, a decision will be made. If the decision is favorable, the FAC awards the accreditation in the name of the CPC for the district area(s) of Facility accreditation set out in Section 2.1 above. The accreditation is then effective immediately. Facility accreditation is valid for as long as the annual ongoing accreditation fee is paid. The managing C Ped (C) or C Ped MC is responsible for ensuring that the accreditation requirements are upheld for the duration of the accreditation period. In the event that an accreditation is revoked or allowed to expire, a complete application must be submitted for re-accreditation Appeal Process The CPC considers and decides upon appeals from those applicants who have not met the requirements as determined by the FAC When Appeal can be Taken Appeals can be launched when the applicant believes that the reasons for the failure in accreditation do not meet the facts contained in their application. Updated April 17,

8 11.2 Appeal Deadlines Appeals must be filed within 30 days after the applicant has received notice of the failed accreditation Addressing the Appeal Appeals shall be addressed to the CPC s FAC Appeal Documentation The appeal must be in writing and should contain any evidence, data, or reasons why the applicant feels the decision of the FAC not to grant accreditation to the applicant, should be reversed Appeal Decision The FAC shall respond to the applicant, in writing, no later than 30 days following its receipt of the applicant s appeal, as to their reasoning for upholding their original decision or allowing the appeal and granting the applicant its accreditation Maintenance of Good Standing The CPC requires a Facility to maintain the standards achieved at the time of accreditation for the duration of the accreditation process Failure to Pay Annual Fees Failure to pay any fees to CPC, by the established due date for such fees, automatically voids the Facility accreditation granted to the Facility in question Minimum Standards Facilities must maintain all standards of the Facility as they were presented to the CPC at the time of accreditation. They must also update standards as notified by the FAC. Any changes to the accreditation process will be communicated to accredited Facilities via mail announcements. Updated April 17,

9 13.0 Temporary Cessation of Facility Accreditation If an accredited Facility encounters a situation that affects the Facility s ability to maintain its standards, it must notify the CPC immediately. The following situations may arise for a facility: A) move to new location; B) change in senior management / certified pedorthist for accreditation; C) destruction or substantial damage to the Facility; and D) new/updated standards Guidelines for Notification Senior management must, in writing, clearly describe the situation to the CPC as to why they are unable to maintain or meet the requirements of Facility accreditation. Since the accreditation is voluntary, the Facility may elect to withdraw itself from accreditation. Alternately, it may submit a list of items that impact its accreditation, and request a Temporary Cessation of Accreditation. Once the Facility manager feels accreditation standards can be successfully demonstrated, s/he can request, in writing, that its accreditation be reinstated. The FAC will then determine if accreditation should be reinstated. Notification of reinstatement of Facility accreditation will be supplied in writing as expeditiously as possible. No fees for this review will apply Duration of Temporary Accreditation Temporary accreditation can be held for a maximum of three months. The Facility must pay their annual dues as they expire to hold their Temporary accreditation. Failure to pay annual dues will cause the Temporary accreditation and Facility Accreditation to Cease Requests for Information Updated April 17,

10 The FAC reserves the right to request applicants for Facility accreditation, to furnish such information and/or references, and to make such additional inquiries about their qualification, as it considers necessary at any time during the accreditation duration (i.e. not just at the time accreditation is granted). Failure to provide such information, may result in the revocation of accreditation Release From Liability Each applicant for Facility accreditation, by signing and filing their application forms, thereby remises, releases and forever discharges the CPC, the directors, officers, agents and employees of CPC, the CPC s FAC and each of its members, and their heirs, executors, administrators, successors and assigns, of and from any and all manner of actions, causes of action, suits, dues, contracts, claims, demands, damages, costs and expenses whatsoever which the applicant ever had, now has or can, shall or may have, from or in respect of or arising out of the application, the timing of the processing of the application, or the granting, refusal to grant or revocation, of accreditation (including, without limitation, the granting of accreditation based on documents submitted by an applicant which are false, incomplete or misleading) Effect of Signing When an authorized representative of a Facility signs its application for accreditation and files it with the CPC for processing, they attest to the truth, completeness and accuracy of the statements it contains. Falsification will cause discontinuance of application processing or revocation of accreditation if it has already been granted Communication of Accreditation Facilities who have been awarded with accreditation will be listed on the CPC website. Updated April 17,

11 Facility Accreditation Application Area of Accreditation Applying For: Custom and Non Custom Foot Orthotic Fabrication / Supply Custom Footwear Fabrication / Supply Stock Footwear Modification / Supply (please check all that apply) Name of Facility Applying for Accreditation: Facility Address: Street: Suite/Unit # City: Prov: Postal Code: Phone: ( ) Fax: ( ) How long has the Facility operated at current address? Name of Company owner(s): Owner s Address: Street: Suite/Unit # City: Prov: Postal Code: Phone: ( ) Fax: ( ) Has the Facility ever operated under a different company name? If so please provide details below. Name(s) of certified Pedorthists upon whom the Facility accreditation will be based: Name of Manager of Facility Certification: Cert. No.: Additional Staff: Name: Certification: Cert. No.: Name: Certification: Cert. No.: Name: Certification: Cert. No.: Name: Certification: Cert. No.: Name: Certification: Cert. No.: Are the members in good standing with the PAC and CPC? YES NO If no indicate their name(s) I attest that the Facility complies with all local business, health, safety, building, privacy and fire regulations. Signature: Manager of Facility Updated April 17,

12 Facility Accreditation Application cont d Has this Facility ever previously applied for accreditation with CPC? YES NO If yes, please provide date and outcome of accreditation application: Date: Outcome: accreditation awarded accreditation not completed accreditation denied If accreditation awarded, please indicate the category:: Custom and Non Custom Foot Orthotic Fabrication / Supply Custom Footwear Fabrication / Supply Non-Custom Footwear Supply / Modification Has the Facility been disciplined under the CPC Facility Audit System in the past 3 years or is it currently being audited? YES NO If yes please explain below Accreditation Fees: Application Fee: $ GST ($265.00) (fee must accompany ALL applications) Annual Fee: Primary Facility: $ GST ($265.00)/HST ($285.00) Secondary Facility: $ GST ($106.00)/HST ($114.00) Payment Type: Cheque (payable to The College of Pedorthics of Canada) Visa MasterCard Amex Diners Club Credit Card Number: Expiration Date: I,, authorize The College of Pedorthics of Canada (fill in name on the credit card) to charge my facility accreditation fees of $. to my credit card. Signature: Date: A fee of $25.00 will be charged for NSF cheques. If credit card transaction is declined because the credit line has reached its spending limit, then a fee of $10.00 will be charged for each declined credit card transaction. Please complete the appropriate attached questionnaires to complete the application. Updated April 17,

13 Custom and Non-Custom Foot Orthotic Fabrication / Supply Questionnaire Please answer the following questions and provide any additional information that is requested or where clarification is required. Attach a separate sheet with clarification information clearly stating which question it pertains to. Are these items available on-sight? YES NO See Attached 1. A private assessment / fitting area? 2. Assessment chair and bench for supine / prone assessment 3. Assessment aids goniometer, foot skeleton, diagrams etc. 4. Adequate space for gait analysis 5. A means of capturing a three dimensional impression 6. Heat source for material molding and modifying 7. Means and materials for adhering post, pads, covers etc. 8. Adequate dust collection and ventilation 9. Grinding equipment 10. Vacuum Former 11. Assortment of Shoe Stretchers Who is doing the fabrication of your orthotics? In House Central Fabricator Central Fabrication Lab (if used) Certification of your fabricators Please list the name and model(s) of your: Grinder(s) Dust collector Adhesives used Main orthotic materials used Updated April 17,

14 Custom Footwear Fabrication / Supply Questionnaire Please answer the following questions and provide any additional information that is requested or where clarification is required. Attach a separate sheet with clarification information clearly stating which question it pertains to. * If you are only a Central Fabricator, answer Questions 6-17 only. Are these items available on-sight? YES NO See Attached 1. A private assessment / fitting area? 2. Assessment chair and bench for supine / prone assessment 3. Assessment aids goniometer, foot skeleton, diagrams etc. 4. Adequate space for gait analysis. 5. A means of capturing a three dimensional impression 6. Heat source for material molding and modifying 7. Means and materials for adhering posting, soles etc. 8. Adequate dust collection and ventilation 9. Grinding equipment 10. Vacuum Former 11. Sewing Machine 12. Lasting Pliers 13. Finishers, polish, laces, etc. 14. Insoles, heel counters, toes boxes 15. Soling material 16. Sole stitcher 17. Assortment of Stretchers Certification of your fabricators Please list the name and model(s) of your: Grinder(s) Dust collector Adhesives used Sewing Machine(s) Updated April 17,

15 Non - Custom Footwear Supply and Modification Questionnaire Please answer the following questions and provide any additional information that is requested or where clarification is required. Attach a separate sheet with clarification information clearly stating which question it pertains to. *For questions 1-4 please list makes and models carried as well as sizes carried in each (including widths). Are these items available on-sight? YES NO See Attached 1. A stock of extra depth, extra width footwear 2. A stock of diabetic specific footwear 3. A stock of Men s and Women s footwear 4. A stock of Children s footwear 5. Adequate space for gait analysis 6. Measurement tools such as a Brannock device or Ritz stick 7. Heat source for material molding and modifying 8. Means and materials for adhering posting, soles etc. 9. Adequate dust collection and ventilation 10. Grinding equipment 11. Vacuum Former 12. Sewing Machine 13. Finishers, polish, laces, etc 14. Insoles, heel counters, toes boxes 15. Soling material 16. Sole stitcher 17. Assortment of Stretchers Certification of your shoe fitters Please list the name and model(s) of your: Grinder(s) Dust collector Adhesives used Updated April 17,

16 Facility Accreditation Process Flowchart Facility completes accreditation documentation Facility sends required documentation, application & annual fee payments to the CPC The CPC reviews accreditation submission Missing documen tation? The CPC requests additional documentation from facility Facility submits additional documentation as requested Accredita tion decision? The CPC communicates to facility: failed accreditation The CPC communicates to facility: successful accreditation Facility appeals? Facility submits decision reversal request with supporting documentation Facility accepts failed accreditation status Accredita tion decision? Updated April 17,